Journal of Psychosomatic Research 61 (2006) 221 – 227

Resilience, misfortune, and mortality: evidence that sense of coherence is a

marker of social stress adaptive capacity
Paul G. Surteesa,b,4, Nicholas W.J. Wainwrighta,b, Kay-Tee Khawc
a
Strangeways Research Laboratory, Worts Causeway, Cambridge, UK
b
Department of Public Health and Primary Care, University of Cambridge, Worts Causeway, Cambridge, UK
c
Clinical Gerontology Unit, Addenbrooke’s Hospital, University of Cambridge School of Clinical Medicine, Cambridge, UK

Received 16 November 2005; received in revised form 6 February 2006; accepted 16 February 2006

Abstract
Objective: The purpose of this study is to test the hypothesis that
sense of coherence (SOC) distinguishes adaptive capacity to adverse
event experience. Methods: A population-based cohort of 20,921
men and women completed a postal assessment of their lifetime
experience of specific adverse events and a measure of their SOC.
Reports of 111,857 events allowed construction of measures of event
impact and adaptation. Results: Those with a weak SOC reported
significantly slower adaptation to the adverse effects of their event
experiences than those with a strong SOC ( Pb.0001). During mean
follow-up of 6.7 years, 1617 deaths were recorded. A one standard
deviation increase in mean adaptation score (representing slower
adaptation) was associated with a 6% increase in mortality rate
( P=.03) after adjusting for age and sex. Measures of event occur-
rence and impact were less strongly associated with SOC and were
not significantly associated with mortality. Conclusion: These
results suggest that SOC is a potential marker of an individual’s
social stress adaptive capacity, which is predictive of mortality.
D 2006 Elsevier Inc. All rights reserved.

Keywords: Adaptation; Life events; Mortality; Resilience; Sense of coherence

Introduction of health status following adverse experience have been

The suggestion that nonspecific physiological systems
are activated by adverse agents that can be both health
protective and restorative but can also promote patho-
genesis was expressed in the early work of Hans Selye [1],
represented through his concept of the bGeneral Adaptation
Syndrome.Q Selye [2] considered that while no disease was
bpurely a disease of adaptation . . . conversely, there is no
disease in which adaptive phenomena play no partQ
(p. 630). Subsequent work has built upon this insight, for
example, through the concepts of ballostasisQ (defined as an
adaptive process to achieve stability through change) and
ballostatic loadQ (representative of the cumulative physio-
logical cost of adaptation) [3,4]. In addition, while studies
4 Corresponding author. Strangeways Research Laboratory, Worts
Causeway, CB1 8RN Cambridge, UK. Tel.: +44 1223 740651; fax: +44
1223 740147.
E-mail address: paul.surtees@srl.cam.ac.uk (P.G. Surtees).
associated with a diversity of outcomes, they have
provided strong evidence of the existence of individual
differences in resilience [5–10]. Such individual differences
have perhaps been most evident in studies of the health
outcomes of people subsequent to their exposure to
profoundly stressful circumstances, including (for example)
concentration camp experience [11], shipwreck [12], and
terrorist attacks [13 – 16]. Not all individuals exposed to
adverse or even traumatic circumstance experience health
change [17,18]. In consequence, identification of individual
differences in adaptive capacity to adversity exposure
could aid understanding of disease susceptibility and
advance coping research.
Sense of coherence (SOC) is a theoretical construct
founded upon the observations of Holocaust survivors.
Antonovsky et al [19] defined SOC to represent the
salutogenic resources available to an individual through
the belief that what happens in their life is comprehensible
(that is rational, predictable, structured, and understand-

0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2006.02.014
222 P.G. Surtees et al. / Journal of Psychosomatic Research 61 (2006) 221–227
able), manageable (in that adequate and sufficient resources
are perceived to be available to aid difficulty resolution as
they arise), and meaningful (such that the demands created
by adversity exposure are seen as challenges and are worthy
of engagement). Sense of coherence was hypothesized,
therefore, as a flexible and adaptive dispositional orientation
enabling successful coping with adverse experience [20].
Based upon data collected from participants in the Norfolk
(UK) European Prospective Investigation into Cancer
(EPIC-Norfolk) study [21], we have previously demonstra-
ted SOC to be strongly associated with mortality [22]. We
now test the hypothesis that SOC distinguishes adaptive
capacity to adverse event experience, specifically, that a
strong SOC will be associated with the report of more rapid
adaptation than a weak SOC and, secondly, that social stress
adaptive capacity, indexed through reports of actual
experience of stressful life events, will be associated with
all-cause mortality.
Method
Participants and measures
During 1993 to 1997, participants were recruited to the
EPIC-Norfolk study through general practice age–sex
registers. The study was approved by the Norwich District
Health Authority Ethics Committee, and all participants
gave signed informed consent (see Ref. [21] for further
details of study design and participant assessments). The
social and psychological status of 20,921 participants (9101
men and 11,820 women) was assessed during 1996 to 2000
through their completion of the Health and Life Experiences
Questionnaire (HLEQ), with a response rate of 73.2% of the
total eligible sample of 28,582 (see Ref. [23] for further
details). All deaths among EPIC-Norfolk HLEQ study
participants to 31st October 2004 were recorded through
linkage with data from the United Kingdom Office for
National Statistics.
Sense of coherence
The HLEQ included a three-item SOC questionnaire [24]
designed to assess the component constructs of comprehen-
sibility, manageability, and meaningfulness by single ques-
tions: (a) bDo you usually feel that the things that happen to
you in your daily life are hard to understand?Q (comprehen-
sibility); (b) bDo you usually see a solution to problems and
difficulties that other people find hopeless?Q (manageability),
and (c) bDo you usually feel that your daily life is a source of
personal satisfaction?Q (meaningfulness). Response choice
was yes, usually (scored 0); yes, sometimes (scored 1); and
no (scored 2). Comprehensibility was reverse scored. The
three items were summed to provide a total SOC scale score
within the range 0 to 6 with a higher score representing a
weaker SOC.
Adverse events in adulthood
Evidence of lifetime adverse event experience was
limited to circumstances considered most likely to be
remembered reliably over an extended period. These were
based upon those included in the questionnaire version of
the List of Threatening Experiences [25,26]. A total of 16
specific adverse events were assessed, including serious
illnesses (injuries or assaults) experienced by the participant
(or a first-degree relative), relationship events (concerning
separation, divorce, or termination of pregnancy), work
events (retirement, redundancy, or being fired), and loss
experiences through death (of first-degree relatives). Partic-
ipants were requested to report up to two most recent
experiences of each specific event. Opportunity was also
provided to report (up to two) other particularly unpleasant
or disappointing lifetime event experiences. In addition to
event timing (within one year of occurrence), participants
were asked to rate the impact of each event (on a four-point
scale: not at all, a little, moderately, extremely) through
answering the question, bHow much did this upset you at
the time?Q and to rate their degree of adaptation to each
event experience by the time of assessment (also on a four-
point scale: completely, mostly, a little, not at all) through
answering the question bDo you feel that you have got over
this now?Q
Statistical analysis
For each participant, the total number of events and mean
impact and adaptation scores of all events reported were
calculated. Events involving participant’s own illness were
excluded from analysis. For each event, responses to the
impact and adaptation questions were assigned numerical
values on a scale from 1 to 4 (for impact: not at all=1, a
little=2, moderately=3, extremely=4; and for adaptation:
completely=1, mostly=2, a little=3, not at all=4). Where no
events were reported, impact and adaptation scores could not
be assigned. Analysis was repeated according to event
subsets of divorce/separation, loss (death of first-degree
relatives), retirement, nonspecific (unpleasant or disappoint-
ing) lifetime event experiences, and other events (not
otherwise listed). Differences in the mean number of events
reported, mean impact, and mean adaptation scores were
evaluated through ANOVA and are presented according to
weak and strong SOC (scored previously as strong=0, 1, and
weak=2 to 6 [22]). Effect sizes are presented as differences in
means divided by the standard deviation (S.D.) (of scale
scores). Progressive adaptation to events with increasing
elapsed time is presented graphically as the mean reported
adaptation score for all events experienced in each year
relative to the time of questionnaire completion. Means and
95% confidence intervals (CIs) for the total number of events
reported and their impact and adaptation are presented
graphically according to increasing SOC scale score
(increasingly weak SOC). For ease of comparison, the scale
 P.G. Surtees et al. / Journal of Psychosomatic Research 61 (2006) 221–227 223

range of the y-axis of each graph is set at two S.D.’s for
each event variable. Because impact scores varied according
to event type, and adaptation scores varied according to both
event type and elapsed time since event occurrence, analysis
was repeated using indices of impact (I-Impact) and
adaptation (I-Adapt) constructed to take this into account
(see Appendix for further details). Percentage variation in
SOC scale scores was calculated through the R 2 statistic
from linear regression. Finally, Poisson regression models,
taking account of duration of follow-up, were used to
investigate the associations between the event variables and
all-cause mortality. Results are presented as rate ratios (95%
CIs) per S.D. increase in each event variable.
Results
Completed SOC scores were available for 20,579 (of
20,921) HLEQ participants (8974 men and 11,605 women,
aged between 41 and 80 years). Internal consistency of the
three-item SOC scale, as measured by Chronbach’s a, was
.35. Of those participants who completed the scale, 8619
were classified as having a strong SOC and 11,960 as
having a weak SOC. The mean SOC scale score was 1.84
(S.D.=1.15). Women reported a weaker SOC than men (with
mean scores 1.68 and 1.96 for men and women, respec-
tively, Pb.0001). Sense of coherence was strongest for those
aged 60 to 69 years (mean scores 1.88, 1.86, 1.78, 1.88, for
those aged 41 to 49, 50 to 59, 60 to 69, 70 to 80 years,
respectively, Pb.0001).
The total number of adverse events reported was 111,857
(mean=5.35, S.D.=2.48, range=0 to 18 out of a possible
maximum of 27 including previous occurrences). Women
reported more events than men (with a mean of 5.27 events
reported by men and 5.41 by women, Pb.0001). Of these
events, 5513 were divorce/separation events, 19,783 retire-
ment events, 9565 nonspecific events, 40,642 loss, and
36,354 other events.
Table 1 shows the mean numbers of reported events
together with their mean impact and adaptation scores
according to SOC scale score. While those with a weak
SOC reported more events than those with a strong SOC,
the magnitude of this difference was small (effect
size=0.04). A more pronounced difference was observed
such that those with a weak SOC reported that their event
experiences upset them more than for those with a strong
SOC (effect size=0.23). However, the largest difference was
observed for adaptation scores, whereby those with a weak
SOC reported that they had not got over the events
experienced to the same extent as those with a strong
SOC (effect size=0.37). Participants with a weak SOC
reported less retirement events than those with a strong SOC
(a difference that persisted with adjustment for age) but
more of all other events (with the biggest difference being
for nonspecific events). Reported impact scores were higher
for those with a weak SOC for all event types, with the
largest difference being for retirement events. Adaptation
scores were consistently higher across all event types
(representing slower adaptation) for those with a weak as
compared to a strong SOC.
Fig. 1A shows mean adaptation scores plotted according
to the timing of (all) reported adverse event experiences
relative to questionnaire completion. The figure confirms
that those with a weak SOC report slower adaptation to the
adverse effects of events than those with a strong SOC, and
also reveals that differences persist for many years. Fig. 1B–
F shows that these differences in adaptation are consistent
across all event types. For all events experienced (Fig. 1A),
the mean difference in adaptation scores for those with a
weak as compared to strong SOC was greatest for those
events experienced within 10 years of HLEQ completion
(mean difference=0.28, effect size=0.38) and was stable
thereafter [difference=0.17, effect size=0.29, for events
experienced 10 to 19 years before questionnaire completion,
0.16 (0.26) for events between 20 and 29 years ago, and
0.16 (0.25) for events experienced 30 years or more prior to
questionnaire completion].
Indices both of impact (I-Impact) and adaptation (I-
Adapt) were calculated to take account of variations by
event type and by timing of event exposures (see
Appendix). I-Impact scores were higher (representing
greater impact) for women than for men (mean
scores= 0.28 for men, and 0.22 for women, effect
size=0.50) and were lower (representing lower impact) for
participants who were older (mean scores 0.12, 0.11, 0.04,
and 0.16 for those aged 41 to 49, 50 to 59, 60 to 69, and
70 to 80 years, respectively; effect size across age
range=0.29). I-Adapt scores were higher (representing

Table 1
Mean number of adverse life events in adulthood, mean impact, and mean adaptation according to a weak vs. a strong SOC
Mean number of events Mean impact Mean adaptation
a a
SOC Weak Strong ES P value Weak Strong ES P value Weak Strong ESa P value
Any event 5.41 5.32 0.04 .006 3.13 2.98 0.23 b.0001 1.57 1.37 0.37 b.0001
Divorce/separation event 0.27 0.26 0.03 .04 3.36 3.27 0.09 .002 1.44 1.24 0.34 b.0001
Retirement events 0.91 1.00 0.10 b.0001 1.61 1.43 0.23 b.0001 1.25 1.12 0.25 b.0001
Loss events 1.98 1.90 0.07 b.0001 3.53 3.44 0.14 b.0001 1.64 1.45 0.30 b.0001
Non specific event 0.50 0.44 0.09 b.0001 3.82 3.77 0.12 b.0001 2.05 1.73 0.35 b.0001
Other events 1.77 1.73 0.03 .04 3.23 3.12 0.13 b.0001 1.45 1.28 0.28 b.0001
a
ES=effect size=difference in means/S.D.
224 P.G. Surtees et al. / Journal of Psychosomatic Research 61 (2006) 221–227

Fig. 1. Mean adaptation scores by elapsed time: (A) all adverse events in adulthood; (B) divorce/separation events; (C) retirement events; (D) loss events;
(E) nonspecific events; and (F) other events, for those with a strong (solid line) and weak (dashed line) SOC.

slower adaptation) for women than for men (mean
scores= 0.17 for men, and 0.13 for women; effect
size=0.30) and were lower (representing more rapid
adaptation) for participants who were older (mean scores
0.10, 0.08, 0.06, and 0.09 for those aged 41 to 49, 50 to
59, 60 to 69, and 70 to 80 years, respectively; effect size
across age range=0.19).
Fig. 2 shows the mean number of events reported, mean
impact, and mean adaptation according to increasing SOC
score (progressively weaker SOC). This reveals that
increasingly weak SOC was associated with progressive
increases in all of these adverse event measures. In addition,
it shows that the magnitude of these differences was again
least for the total number of events reported, greater for
impact scores, and greater still for adaptation. The pattern of
results was the same for I-Impact and I-Adapt, and the
magnitude of differences was greater as compared to their
respective crude measures (data not shown). The percentage
variation in SOC scale scores explained by these adverse
event measures was least for the total number of adverse
events experienced (only 0.1% of variation explained),
greater for impact scores (1.9%), and greater still for
adaptation (5.6%). Percentage variation explained by I-
Impact was 2.0% and by I-Adapt was 5.8%.
During mean follow-up of 6.7 years, 1617 deaths were
recorded (including 939 men and 678 women). Table 2
shows that neither adverse event experience nor impact was
associated with mortality, but that stress adaptive capacity
was associated with mortality. One S.D. increase in
adaptation was associated with a 6% increase in mortality
rate ( P=.03) after adjustment for age and sex. Similarly, I-
Impact was not associated with mortality, whereas a 1 S.D.

Fig. 2. Association (means and 95% CIs) between measures of adverse event experience in adulthood and SOC score (higher score represents progressively
weaker SOC). (A) Number of events; (B) impact scores; (C) adaptation scores. Plotted range on y-axis is standardized at two S.D.’s for each adversity variable.
 P.G. Surtees et al. / Journal of Psychosomatic Research 61 (2006) 221–227
Table 2
Association between the number of adverse events reported, mean impact
and mean adaptation (of all events reported), and all-cause mortality
(adjusted for age and sex)
Deaths Rate ratio 95% CI
1617
Events reported 0.98 (0.93–1.03)
Mean impact 1.03 (0.98–1.09)
Mean adaptation 1.06 (1.01–1.12)
Rate ratios (95% CIs) per S.D. increase in each measure.
increase in I-Adapt score was associated with a 7% increase
in mortality rate after adjustment for age and sex (rate
ratio=1.07; 95% CI, 1.02–1.13; P=.008).
Discussion
This study has provided strong evidence in support of the
hypothesis that SOC distinguishes adaptive capacity to
adverse event experience. Specifically, study participants
with a strong SOC reported more rapid adaptation to their
experience of social adversity than those with a weak SOC,
whether social adversity was defined by all types of events
or just when restricted to specific circumstances. In addition,
the results suggested that a relatively slower capacity to
adapt to the consequences of adverse experience was
associated with increased mortality, whether adaptive
capacity was defined by either a crude (mean) measure of
adaptation or the I-Adapt index, that included consideration
of adverse event type and event timing. In contrast,
measures of event occurrence and impact were less strongly
associated with SOC and were not associated with mortality.
These results may be seen to provide support to some of the
fundamental ideas underlying Antonovsky’s concept of
salutogenesis, including a focus on bactive adaptation to
an inevitably stressor-rich environmentQ (see Ref. [20], p. 9),
recognition that bthe greater the stressor load, the more
important the role of salutary factorsQ (see Ref. [27], p. 159),
and that adverse experiences bare open-ended in their
proximal as well as their distal consequences for healthQ
(see Ref. [28], p. 970).
While the current study has major design strengths,
including the cohort size (with nearly 21,000 participants
and over 100,000 adverse life events assessed), and
prospective ascertainment of mortality (with 1617 deaths
from all-causes over a 7-year follow-up), a number of
potential limitations may restrict the generalizability of
findings. The study cohort is an older population (age range,
41 to 80 years). The study design includes a retrospective
account of lifetime experience of stressful life events, the
design relies on a single assessment of SOC contempora-
neous with the assessment of adversity, and SOC was
operationalized by Antonovsky [20] initially as a 29-item
questionnaire, whereas the assessment in this study was
based upon a simplified three-item measure. While the
internal consistency of the three-item measure was low in
225
this sample (Chronbach’s a=.35), this is likely to be partially
due to the small number of scale items. In addition, the
original developers of the scale reported satisfactory short-
term test–retest reliability and validity for the three-item
measure (see Ref. [24] for further details). However, other
studies using longer scales have questioned the stability of
SOC over time periods of up to 5 years [29,30].
Previous analysis of this cohort revealed a strong
relationship between SOC and all-cause mortality, such that
a one S.D. increase in SOC scale score (representing weaker
SOC) was associated with a 19% increased rate of mortality
(see Ref. [22,31] for further details), and with some support
from other work [32]. While the association observed here
between adaptation to the adverse effects of life events and
all-cause mortality was not of the same magnitude, together,
these results provide evidence that the association between
SOC and mortality may be partially mediated by an
individual’s capacity to deal with stressful situations.
While recent evidence has been published demonstrating
that SOC moderates the impact of negative life events
(experienced during the previous 12 months) on self-reported
health status [33], we are unaware of any other study that has
reported a comprehensive test of the hypothesis that SOC is a
marker of social stress adaptive capacity with which to
compare findings. However, our results may be seen to
contribute to recent debates concerning individual differ-
ences in the human capacity to cope with adverse experience.
In particular, these include issues arising from resilience
research [9,18,34], from the study of positive (change or)
adaptation to trauma [35,36], from wisdom research
[35,37,38], and from tests of set-point theory [39]. With
differing degrees of emphasis, these interrelated research
areas have focused on identifying and extending under-
standing of individual differences (or contexts) that differ-
entiate the process of human adaptation to adversity.
For example, research has suggested that higher mental
ability assessed in childhood is inversely associated with
adult mortality [40,41], with speculation that the association
may, at least in part, implicate psychometric intelligence as a
significant influence on effective health self-care [42]. Other
recent work has shown a strong SOC to be associated with
improved health biomarkers [43,44] and with the adoption of
health-promoting dietary habits [45]. The results of this study
may therefore stimulate investigation of the joint association
between SOC and wisdom-related measures. Future evalua-
tion of set-point theory may also benefit through consid-
eration of interrelationships with SOC. Recent tests, based
upon assessment of progressive adaptation following marital
status changes, including death of partner [46] and following
unemployment [39], noted substantial individual differences
in the capacity of individuals to adapt to these experiences,
and that these were probably influenced by personality.
Collectively, therefore, our findings strengthen the rationale
underlying these research areas, underpin other evidence
concerning the human capacity for resilience, show SOC
powerfully to distinguish social stress adaptive capacity, and
226 P.G. Surtees et al. / Journal of Psychosomatic Research 61 (2006) 221–227
provide evidence to our knowledge for the first time that
individual differences in stress adaptability are predictive of
all-cause mortality.
Acknowledgments
EPIC-Norfolk is supported by program grants from the
Medical Research Council UK (G9502233, G0300128) and
Cancer Research UK (C865/A2883) with additional support
from the European Union, Stroke Association, British Heart
Foundation, Department of Health, Food Standards Agency,
and the Wellcome Trust.
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Appendix. Derivation of indices of event impact
(I-Impact) and adaptation (I-Adapt)
Indices of event impact (I-Impact) and adaptation (I-
Adapt) were derived to take account of variations by event
type and (for adaptation) by event timing. For each event
reported, responses to the impact and adaptation questions
were assigned numerical values on a scale from 1 to 4 (for
impact: not at all=1, a little=2, moderately=3, extremely=4;
227
and for adaptation: completely=1, mostly=2, a little=3, not
at all=4). Impact scores were centered according to event
type (through subtraction of the sample mean impact score
for all reported events of the same event type), and
adaptation scores were centered according to event type
and the elapsed time since event occurrence (through
subtraction of the sample mean adaptation score for all
events of the same type reported in the same year relative to
questionnaire completion). For each individual, I-Impact
and I-Adapt were derived as the mean centered impact and
adaptation scores for all events reported by that individual.
Where no events were reported (for 412 and 969 partic-
ipants, respectively), these indices could not be calculated.
In addition, the S.D.’s of I-Impact and I-Adapt were greater
for participants who reported fewer events (where the
number of event experiences on which I-Impact and I-
Adapt were based varied from 1 to 18 and 1 to 15,
respectively). Finally, therefore, I-Impact and I-Adapt were
standardized, first, such that their S.D.’s were constant
according to the number of events experienced, and second,
to have mean=0 and S.D.=1. A positive I-Impact score
represents a higher impact of adverse events experienced
than the sample mean, and a positive I-Adapt score
represents slower adaptation to the adverse effects of the
adverse events experienced than the sample mean.